| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,202 |
1,071 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
524 |
440 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
869 |
774 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
123 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
360 |
$15K |
| D1206 |
Topical application of fluoride varnish |
462 |
408 |
$9K |
| D0274 |
Bitewings - four radiographic images |
267 |
242 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
168 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
39 |
$4K |
| D1120 |
Prophylaxis - child |
43 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$204.00 |
| D0350 |
|
40 |
39 |
$45.56 |
| D1999 |
|
224 |
212 |
$0.00 |